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General NPI Number Information
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NPI Number | 1326381583
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Entity Type | Organization
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Legal Business Name | REVIVE NATUROPATHIC MEDICINE, INC.
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Dates
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Enumeration Date | 04/05/2013
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Last Update Date | 06/14/2022
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Provider Practice Location Address
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Address Line | 560 CARLSBAD VILLAGE DR 202C
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City | CARLSBAD
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State | CA
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Zip | 92008-2391
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Country | US
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Telephone | 760-452-0763
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Fax |
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Provider Business Mailing Address
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Address Line | 4085 HARRISON ST #3
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City | CARLSBAD
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State | CA
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Zip | 92008-3586
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Country | US
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Telephone | 503-577-8184
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DEREK LAWRENCE
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Credential | N.D
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Telephone | 760-306-4842
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175F00000X
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Taxonomy Name | Naturopath
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License Number | CA-560
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License Number State | CA
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